Provider Demographics
NPI:1639654148
Name:SHAPIRO, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7209 PROMENADE DR APT 601
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-2809
Mailing Address - Country:US
Mailing Address - Phone:561-271-9497
Mailing Address - Fax:888-857-7246
Practice Address - Street 1:7209 PROMENADE DR APT 601
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2809
Practice Address - Country:US
Practice Address - Phone:561-271-9497
Practice Address - Fax:888-857-7246
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3126213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101996200Medicaid